CBT is the first line of treatment and includes two components, cognitive therapy (CT) and exposure and response prevention (ERP). CT helps individuals with OCD as they become anxious about their obsessions, or thoughts. The goal of CT is to train patients to interpret their obsessions and to challenge their beliefs or assumptions about them, their attitude toward them, and the reasoning behind them. Individuals who fear using public restrooms, as an example, may believe they will acquire disease-causing germs. By challenging the interpretation of this fear, using public restrooms can begin to no longer be interpreted as a dangerous activity. Effective relief of anxiety and results require time and patience.
In addition to interpreting and challenging beliefs, CT assists patients in identifying and reevaluating beliefs about the potential consequences of performing or not performing compulsive behavior. The ultimate goal of therapy is to eliminate this behavior. A compulsive hand washer who does so for 20 minutes several times a day may believe he or she is performing the behavior to ward off disease. When this belief is challenged and revised, it can help control the behavior.
ERP, the most widely practiced behavioral therapy for OCD, is often used in combination with CT to manage symptoms. The first step in ERP exposes individuals to anxiety-provoking stimuli that trigger obsessions. In the case of someone with compulsive hand washing, the anxiety-provoking stimuli include dirt and germs. With repeated exposure to stimuli, anxiety lessens over time and specific stimuli eventually produce little anxiety. This process of becoming used to the anxiety-provoking stimuli is known as habituation.
The second step in ERP, response prevention, involves the rituals that individuals with OCD engage in to reduce anxiety. Response prevention teaches people to stop engaging in abnormal behaviors. In other words, response prevention helps individuals resist the compulsive urge to continuously wash their hands.
A trained psychotherapist in CBT may begin ERP treatment with compulsive hand washers by asking them to list anxiety-provoking situations, in order of mild to severe symptoms. Individuals who fear germs and contamination, for instance, may create a list similar to this:
- touching garbage
- using a public restroom
- shaking hands
Using this list, the therapist gradually exposes the patient to the situation that causes the least anxiety. When the patient is exposed to germs, the therapist may demonstrate a more typically way to wash his or her hands, rubbing with soap and rinsing off after a minute or two. As the patient habituates to this situation, the therapist then presents him or her with the next situation that causes greater anxiety. ERP sessions typically last between 45 minutes to three hours. Since each patient differs in abilities to tolerate anxiety and to resist compulsive behaviors, habituation time varies. After the therapist initially assists patients with exposure activities, patients are asked to practice tasks between sessions for a few hours every day.
The primary goal of ERP is for the patient to stay in contact with the anxiety-provoking stimuli without engaging in ritualistic behaviors. An individual who fears germs and responds to the anxiety by repeatedly washing hands, for example, would have to resist such activities - first for hours, then days following an exposure activity. Therapy continues until the patient has the ability to stop rituals altogether. Another aspect of exposure activities involves training patients to become experts in rating their own anxiety levels. After progress is made in therapy sessions, patients are encouraged to continue using ERP technique, and to apply them to new situations.